SANDY SPRINGS — In Tonisha Caulder’s hospital bag, she has two tablets, an old cellphone and a jumble of charging cords.

The extra electronics ensure her doula can be with her — at least in a way — during the birth of her first child, a boy, due to come at the end of the month.

With her family five hours away in South Carolina, Caulder chose to hire Zaire Sabb, a local doula, to be her “army” during pregnancy.

But COVID-19 upended the hospital system; visitors in the labor room are limited to one at Caudler’s hospital. Sabb cannot be by her side.

“It’s really difficult because I had to choose between my partner — we’re delivering our first child together — and this person that I’ve come to trust as like my life coach,” she said. “I anticipated this person being there, being with me, guiding me through this situation that I’ve never been in and that’s very scary.”

Doulas are trained, nonclinical companions who often support a mother emotionally and physically throughout the duration of her pregnancy from accompanying her to prenatal doctors visits to coaching the mom on how to breastfeed post-pregnancy.

For black women in Georgia, who are at higher risk of maternal mortality, many rely on a doula to be their advocate in the delivery room.

Since the coronavirus outbreak, hospitals have instituted a patchwork of labor and delivery visitor policies to prevent further spread of the virus both in and out of the health care system. The rules vary place to place and change frequently with the severity of the pandemic, placing on mothers the tough decision about who will be with her while giving birth.

The change has forced doulas out of delivery rooms and onto FaceTime. From afar, they try to bring the same level of support they promised their clients.

While some hospitals have made exemptions and recognized doulas as part of the birthing team, advocates said, many still don’t — leaving first-time mothers and their partners uncertain of what to expect when entering labor.

‘It’s a very scary time’

As a state, Georgia is already faced with a maternal mortality crisis — black women are nearly three times more likely to die during childbirth than white women during pregnancy.

According to the state’s Maternal Mortality Review Committee, from 2012-15, Georgia saw a rate of 67 maternal deaths per 100,000 live births — two-thirds of which were deemed preventable. The state rate is nearly four times higher than the national rate of 17.4 maternal deaths per 100,000 live births.

“We all know the statistics and the disparities for black moms,” Caulder said. “I don’t particularly trust the institution to take care of me.”

While various national and global studies indicate having a doula can improve pregnancy outcomes — doulas have been shown to lower the rate of cesarean sections and even improve infant birthweight — they have been trying to prove their presence in the delivery room is “essential.”

“Because of the COVID-19 pandemic most doulas are no longer allowed to go with our clients to the hospital or to the doctor’s offices,” Dr. Elizabeth Mosley, a full-spectrum doula and post-doctoral fellow at Emory University, said. “So instead of seeing doulas like a member of the health care team, we’re being treated as outsiders.”

When Sabb worked in a pediatric intensive care unit as a nurse, she said, it startled her how many parents would detail things that went wrong during the birth, from a prolonged labor or unwanted induction to the baby being taken away immediately after delivery.

Now amid a viral pandemic, she said, mothers face heightened fear of possibly contracting coronavirus while in the hospital or having their baby taken away for an isolation period if they show any symptoms when they arrive.

“You just spent nine to 10 months with this human in your body,” Sabb said. “And as soon as they come out, they could be taken away from you.”

The fear has pushed many of her clients to request switching to a home birth, she said, which isn’t always realistic at the last minute and adds significant expenses due to lack of insurance coverage for midwives that help with home births. That’s on top of already out-of-pocket doula rates.

“It’s a very scary time because some people are going into labor and delivery by themselves,” Mosley said. “Some are now going through emergency cesarean operations without the support of a loved one or doula. It’s really dire.”

Before the pandemic, doulas and birth advocates in Georgia were already looking at how to expand doula services to vulnerable populations, a majority of whom are least likely to be able to afford it.

“We’re already a state where folks know that pregnancy can be dangerous. In Georgia, there are still a lot of people dying during childbirth, especially black women,” Mosley said. “Now even more, what I’m seeing among pregnant women or pregnant people in Georgia is the fear of where can I deliver that’s going to be safe.”

Changing plans

Mothers and doulas alike recognize hospitals need to mitigate possible spread of coronavirus, said Amber Mack, research and policy analyst with Healthy Mothers, Healthy Babies Coalition of Georgia, but she thinks hospitals should consider the need for doulas. 

“If a mother has to choose between the father or child or maybe her own parent and her doula,” Mack said, “often times she’s obviously going to choose the loved one or a family member. Because of that, doulas are being impacted when they should be considered a part of the care team.”

As the pandemic impacted Georgia, the coalition surveyed 76 of the state’s hospitals on their labor room visitor polices from March 27 to April 9. Out of the 73 that responded, 90% had a one visitor policy with no exception for doulas.

Although many policies have changed since, Healthy Mothers, Healthy Babies has put out a guidebook for doulas who must use virtual care.

Corinna Edwards, founder of Bellies to Babies, a doula training organization, said the uncertainty of hospital policies increases the stress.

“Fear doesn’t belong in the birthing room, especially with low risk women if everything’s healthy and normal,” she said. “It’s really sad to say that a lot of mothers right now are scared. With pregnancy, there’s already a lot of unknown, so for mothers to have this additional unknown about the hospital’s policy and who they will allow just adds to it.”

For weeks now, Caulder hasn’t been able to stop herself from refreshing her hospital’s visitor policies web page regularly. In April, the policy changed from two visitors to one, and it hasn’t changed since.

“No woman that’s about to give birth is diminishing the severity of the COVID-19 crisis,” she said. “No one thinks that it’s not important for the hospital to protect us. But at the same time, I do think there should be more consideration given to birth partners and one other person.”

Even with the compromise of virtual doula support on FaceTime, Caulder said she is unsure how the nurses and doctors on duty will react — with many hospitals upholding strict, longtime policies of no filming in the delivery room.

Caulder will labor at home with the physical support of Sabb for as long as possible before making the short drive to the hospital, where she’s preparing herself to be screened for coronavirus and reconnect with her doula as soon as possible.

“Culturally, it is really important to have someone there who can provide uninterrupted support who recognizes the things that you need because the community that you’re from,” Edwards said. “I think that’s really important when we talk about mortality, when we know that there’s systemic racism and that black women, especially, are not always believed if they have something going on.”